Form Eoir-42b - Application For Cancellation Of Removal And Adjustment Of Status For Certain Nonpermanent Residents Page 11
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13PART 7 - MISCELLANEOUS INFORMATION
(Continued)
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57) Have you ever deserted from the military or naval forces of the United States while the United States was at war?
Yes
No
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58) If male, did you register under the Military Selective Service Act or any applicable previous Selective Service (Draft) Laws?
Yes
No
If “Yes,” please give date, Selective Service number, local draft board number, and your last draft classification:
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59) Were you ever exempted from service because of conscientious objection, alienage, or any other reason?
Yes
No
60) Please list your present or past membership in or affiliation with every political organization, association, fund, foundation, party, club, society,
or similar group in the United States or any other place since your 16 th birthday. Include any foreign military service in this part. If none, write
“None.” Include the name of the organization, location, nature of the organization, and the dates of membership.
Member From:
Member To:
Name of Organization
Location of Organization
Nature of Organization
(Month, Day, Year)
(Month, Day, Year)
61) Have you ever:
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Yes
No
been ordered deported, excluded, or removed?
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Yes
No
overstayed a grant of voluntary departure from an Immigration Judge or the Department of Homeland Security (DHS),
formerly the Immigration and Naturalization Service (INS)?
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Yes
No
failed to appear for removal or deportation?
62) Have you ever been:
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Yes
No
a habitual drunkard?
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Yes
No
one whose income is derived principally from illegal gambling?
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Yes
No
one who has given false testimony for the purpose of obtaining immigration benefits?
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Yes
No
one who has engaged in prostitution or unlawful commercialized vice?
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Yes
No
involved in a serious criminal offense and asserted immunity from prosecution?
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Yes
No
a polygamist?
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Yes
No
one who brought in or attempted to bring in another to the United States illegally?
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Yes
No
a trafficker of a controlled substance, or a knowing assister, abettor, conspirator, or colluder with others in any such
controlled substance offense (not including a single offense of simple possession of 30 grams or less of marijuana)?
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Yes
No
inadmissible or deportable on security-related grounds under sections 212(a)(3) or 237(a)(4) of the INA?
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Yes
No
one who has ordered, incited, assisted, or otherwise participated in the persecution of an individual on account of his or
her race, religion, nationality, membership in a particular social group, or political opinion?
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J
Yes
No
a person previously granted relief under sections 212(c) or 244(a) of the INA or whose removal has previously been
cancelled under section 240A of the INA?
If you answered “Yes” to any of the above questions, explain:
Please continue answers on a separate sheet as needed.
Form EOIR-42B
Revised July 2014
(6)
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